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Transitional Care Coordination

We understand that being treated for cancer can be difficult and confusing. This is particularly true when your treatment is provided in multiple locations such as an outpatient clinic, inpatient hospital room, a skilled nursing facility, rehabilitation hospital, or even at home. We know that successful coordination of your care requires detailed planning across these many different treatment locations.

Moving between care settings, such as from a hospital admission to home, is referred to as “transitions in care.” Oncology transitional care coordinators are medical social workers working with your oncology team to ensure seamless transitions in your care while providing emotional support to you and your families during a stressful time.

Should You Contact a Transitional Care Coordinator?

The good news is that you do not need to contact a Transitional Care Coordinator; we will come to you when you are admitted to our hospital. The Transitional Care Coordinator is part of your cancer care team and will work with you and your family to make sure that all aspects of your cancer care are coordinated and seamless for you.

The Transitional Care Coordinator will assist you by:

Coordinating all of your outpatient appointments after being discharged from the hospital

Ensuring that you and your family understand your hospital discharge instructions

Giving you one person to contact if you need answers to your questions

Helping you and your family deal with the emotional aspects of your transitions

Helping you and your family identify the community resources that may help you

Making sure that you have the necessary medical equipment in your home